http://ijhpm.com Int J Health Policy Manag 2016, 5(2), 129–131
doi 10.15171/ijhpm.2015.195
Commentary Putting Management Capacity Building at the Forefront of Health Systems Strengthening Comment on “Management Matters: A Leverage Point for Health Systems Strengthening in Global Health” Valerie A. Yeager*, Jane Bertrand Abstract The current limited focus on management in global health activities is highly problematic given the amounts of financial and human resources that are pouring into health system strengthening interventions and the complexity of clinical operations across settings. By ensuring that public health and healthcare practitioners in domestic and international settings receive management training in their educational programs and that we build management capacity among individuals already in the health workforce, we can begin to prepare for more effective health systems strengthening efforts. Rigorous evaluation of health systems strengthening and the impact of management capacity building is crucial to building evidence for the field. Keywords: Health System Strengthening, Management, Strategy, Global Health Copyright: © 2016 by Kerman University of Medical Sciences Citation: Yeager VA, Bertrand J. Putting management capacity building at the forefront of health systems strengthening: Comment on “Management matters: a leverage point for health systems strengthening in global health.” Int J Health Policy Manag. 2016;5(2):129–131. doi:10.15171/ijhpm.2015.195
Introduction Healthcare management has long been a part of improving formal healthcare organizational performance, but the tools and skills that accompany this field are less commonly employed in broader health contexts such as global health systems strengthening and public health efforts.1 The recent article by Bradley et al draws attention to this gap in the field of health systems strengthening and global health.2 Their article initiates an important discussion and lays out a three part strategy for addressing this important missing component of the various activities and frameworks at the core of global health systems strengthening efforts. Well over a decade into the formal development of health systems strengthening, it is beyond time that we acknowledge the value of management in “achieving large ends with limited means.”2 As Bradley and colleagues note, the limited focus on management in global health activities is highly problematic given the amounts of financial and human resources that are pouring into health system interventions and the complexity of clinical operations across settings. Furthermore, given the heightened reporting requirements and pressure to show population health improvements resulting from international health aid, integrating management capacity building into health systems strengthening activities will be beneficial not only for health systems and population health, but also for funding accountability. Encouraging increased incorporation of management in global health systems strengthening, Bradley and colleagues suggest a focus on training and education, practice, and research. As a starting point, the authors provide an important
Article History: Received: 15 August 2015 Accepted: 25 October 2015 ePublished: 26 October 2015
*Correspondence to: Valerie A. Yeager Email: [email protected]
contribution via their succinct list of core competencies and illustrative examples to improve the management of global health efforts. While this list does not deviate much from traditional health management educational competencies, the authors’ explanations of the various ways these competencies can be applied in global health systems strengthening efforts is useful to making the connection between health systems strengthening and the potential of management contributions. Changing Who and How We Train and Educate Educators in public health management and policy have long fought the assumption that only those students interested in clinical healthcare management need management skills. Working within the time and course credit limitations of academic health programs, we must find ways to ensure that the management competencies outlined by Bradley et al are incorporated into the training of both clinical health professionals and public health professionals. Many health professionals begin working in technical positions, and those who perform well are often promoted to managerial positions, without the benefit of formal management training. For example, it is not unusual to have nurses managing healthcare facilities in many settings across the globe, especially in lowincome countries where broad health system strengthening initiatives are underway. However, nurse training rarely includes human resource, performance, or financial management – all skills that Bradley et al argue are crucial to broader health system performance improvement.3-5 Educators and educational institutions have a role in rewriting this story. We can begin by working to change the long-held
School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
Yeager and Bertrand
assumption that management training is only for individuals working in high-level leadership roles. Building management capacity does not have to solely take place in formal degree programs. It can also occur via distance-based seminars and one- or two-week in-country workshops for health managers.6 By ensuring that public health and healthcare practitioners in domestic and international settings receive management training in their educational programs and that we build management capacity among individuals already in the health workforce, we can begin to prepare for more effective health systems strengthening efforts. This is not to say that there are not longstanding efforts to improve and develop management skills among public health and healthcare professionals, but that management capacity building needs even more emphasis. Schools and programs of public health in the United States, the United Kingdom, and Europe have successful management programs and train numerous graduates in health management; however, we need to extend the reach of these programs and make training around management skills and tools more widely available in low-income settings and outside of formal degree programs. Doing so may foster the use of these skills and tools among healthcare staff and facilities in the structures and systems of countries without long-established schools of public health or business.7 Bradley and colleagues highlighted the potential value of academic programs specifically focused on health administration such as bachelors and masters programs in schools of public health with management concentrations or schools of business with healthcare concentrations.2 Collaborative programs or educational partnerships between such institutions and healthcare organizations are increasingly common in low-income settings and locations without easy access to similar training programs.8-11 Educational partnerships can be implemented fairly quickly and may be more cost-effective than establishing an academic program from scratch. Bradley et al suggest that Ministries of Health could play a role in funding access to such partnership programs. This may be financially feasible in some emerging nations; however, for many low-income nations this may be unrealistic. An alternative strategy may be to encourage and facilitate management capacity building through health systems strengthening project funding and donor agencies. Encouraging or even requiring management capacity building for funded health systems strengthening activities may be a good start. Management capacity building whether through new academic partnerships or revisions to current health training programs has the potential to change the effectiveness of global health systems strengthening. Evidence on Management in Health System Strengthening Like the field of health system strengthening, little evidence exists to inform management needs and best practices.12,13 At the macro level, better evidence can inform global health policies and donor funding that could support and justify more capacity building around management. At the micro level, better evidence can influence health systems strengthening activities and more effective management systems. A stronger 130
commitment to the monitoring and evaluation of health systems strengthening efforts, specifically those implementing quality improvement initiatives or management capacity building may contribute to filling this knowledge gap. While this may sound simple, measuring progress in health systems strengthening requires careful planning and sound metrics to assess changes in health systems function and performance. And although health systems strengthening has received considerable attention over the past decade, how to go about the process of monitoring and evaluating these activities is not always clear. Some assume that evaluating health system strengthening activities is too difficult given the nature of the work. Indeed, evaluation of these broad activities can be complex; however, our experiences with practitioners suggests that the amount of time, resources, and financial support necessary to conduct a rigorous evaluation of a health system strengthening activity is often underestimated and more limiting than study design issues. These issues aside, rigorous evaluation of health systems strengthening and the impact of management capacity building is crucial to building evidence for the field. As witnessed by the article by Bradley and colleagues, we appear to have arrived at a point in time where the value of management in global health efforts is getting some attention. How well we integrate management in health system strengthening activities will likely be determined by efforts toward management training and education and partnerships and the quality of the research that feeds back in to improve the system. Ethical issues Not applicable.
Competing interests
Authors declare that they have no competing interests.
Authors’ contributions
VAY conceptualized and drafted the manuscript. JB provided critical revisions to the manuscript. Both VAY and JB approved the final version.
References 1. Royston G. Meeting global health challenges through operational research and management science. Bull World Health Organ. 2011;89(9):683-688. doi:10.2471/blt.11.086066 2. Bradley EH, Taylor LA, Cuellar CJ. Management matters: a leverage point for health systems strengthening in global health. Int J Health Policy Manag. 2015;4(7):411-415. doi:10.15171/ ijhpm.2015.101 3. Kleinman CS. Leadership roles, competencies, and education: how prepared are our nurse managers? J Nurs Adm. 2003;33(9):451-455. doi:10.1097/00005110-200309000-00005 4. Baker S, Marshburn DM, Crickmore KD, Rose SB, Dutton K, Hudson PC. What do you do? Perceptions of nurse manager responsibilities. Nurs Manage. 2012;43(12):24-29. doi:10.1097/01.numa.0000422890.99334.21 5. Kerridge J. Why management skills are a priority for nurses. Nurs Times. 2013;109(9):16-17. 6. Novak S. Hands-On Medical Education in Rwanda. The New York Times. May 13, 2012. http://www.nytimes.com/2012/05/14/ world/africa/14iht-educlede14.html?pagewanted=all&_r=1. Accessed August 8, 2015.
International Journal of Health Policy and Management, 2016, 5(2), 129–131
Yeager and Bertrand 7.
Potter C, Brough R. Systemic capacity building: a hierarchy of needs. Health Policy Plan. 2004;19(5):336-345. doi:10.1093/ heapol/czh038 8. Institute of Medicine (IOM). The US Commitment to Global Health: Recommendations for the Public and Private Sectors. Washington (DC): National Academies Press (US); 2009. 9. Novak S. Hands-On Medical Education in Rwanda. The New York Times. Accessed May 13, 2012. http://www.nytimes. com/2012/05/14/world/africa/14iht-educlede14.html?_r=0. 10. Díaz-Monsalve, SJ. The impact of health-management training programs in Latin America on job performance. Cad Saude Publica. 2004;20(4):1110-1120. 11. Egger D, Travis P, Dovlo D, Hawken L. Strengthening
Management in Low-Income Countries. Making Health Systems Work: Working Paper Series Number 1. Geneva: World Health Organization; 2005. http://www.who.int/management/working_ paper_1_en_opt.pdf. Accessed October 23, 2015. 12. Adam T, Hsu J, de Savigny D, Lavis JN, Rottingen JA, Bennett S. Evaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions? Health Policy Plan. 2012;27(suppl 4):iv9-19. doi:10.1093/heapol/czs086 13. Hatt L, Johns B, Connor C, Meline M, Kukla M, Moat K. Impact Of Health Systems Strengthening on Health. Bethesda, MD: Health Finance & Governance Project. Abt Associates; 2015.
International Journal of Health Policy and Management, 2016, 5(2), 129–131
131
doi 10.15171/ijhpm.2015.195
Commentary Putting Management Capacity Building at the Forefront of Health Systems Strengthening Comment on “Management Matters: A Leverage Point for Health Systems Strengthening in Global Health” Valerie A. Yeager*, Jane Bertrand Abstract The current limited focus on management in global health activities is highly problematic given the amounts of financial and human resources that are pouring into health system strengthening interventions and the complexity of clinical operations across settings. By ensuring that public health and healthcare practitioners in domestic and international settings receive management training in their educational programs and that we build management capacity among individuals already in the health workforce, we can begin to prepare for more effective health systems strengthening efforts. Rigorous evaluation of health systems strengthening and the impact of management capacity building is crucial to building evidence for the field. Keywords: Health System Strengthening, Management, Strategy, Global Health Copyright: © 2016 by Kerman University of Medical Sciences Citation: Yeager VA, Bertrand J. Putting management capacity building at the forefront of health systems strengthening: Comment on “Management matters: a leverage point for health systems strengthening in global health.” Int J Health Policy Manag. 2016;5(2):129–131. doi:10.15171/ijhpm.2015.195
Introduction Healthcare management has long been a part of improving formal healthcare organizational performance, but the tools and skills that accompany this field are less commonly employed in broader health contexts such as global health systems strengthening and public health efforts.1 The recent article by Bradley et al draws attention to this gap in the field of health systems strengthening and global health.2 Their article initiates an important discussion and lays out a three part strategy for addressing this important missing component of the various activities and frameworks at the core of global health systems strengthening efforts. Well over a decade into the formal development of health systems strengthening, it is beyond time that we acknowledge the value of management in “achieving large ends with limited means.”2 As Bradley and colleagues note, the limited focus on management in global health activities is highly problematic given the amounts of financial and human resources that are pouring into health system interventions and the complexity of clinical operations across settings. Furthermore, given the heightened reporting requirements and pressure to show population health improvements resulting from international health aid, integrating management capacity building into health systems strengthening activities will be beneficial not only for health systems and population health, but also for funding accountability. Encouraging increased incorporation of management in global health systems strengthening, Bradley and colleagues suggest a focus on training and education, practice, and research. As a starting point, the authors provide an important
Article History: Received: 15 August 2015 Accepted: 25 October 2015 ePublished: 26 October 2015
*Correspondence to: Valerie A. Yeager Email: [email protected]
contribution via their succinct list of core competencies and illustrative examples to improve the management of global health efforts. While this list does not deviate much from traditional health management educational competencies, the authors’ explanations of the various ways these competencies can be applied in global health systems strengthening efforts is useful to making the connection between health systems strengthening and the potential of management contributions. Changing Who and How We Train and Educate Educators in public health management and policy have long fought the assumption that only those students interested in clinical healthcare management need management skills. Working within the time and course credit limitations of academic health programs, we must find ways to ensure that the management competencies outlined by Bradley et al are incorporated into the training of both clinical health professionals and public health professionals. Many health professionals begin working in technical positions, and those who perform well are often promoted to managerial positions, without the benefit of formal management training. For example, it is not unusual to have nurses managing healthcare facilities in many settings across the globe, especially in lowincome countries where broad health system strengthening initiatives are underway. However, nurse training rarely includes human resource, performance, or financial management – all skills that Bradley et al argue are crucial to broader health system performance improvement.3-5 Educators and educational institutions have a role in rewriting this story. We can begin by working to change the long-held
School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
Yeager and Bertrand
assumption that management training is only for individuals working in high-level leadership roles. Building management capacity does not have to solely take place in formal degree programs. It can also occur via distance-based seminars and one- or two-week in-country workshops for health managers.6 By ensuring that public health and healthcare practitioners in domestic and international settings receive management training in their educational programs and that we build management capacity among individuals already in the health workforce, we can begin to prepare for more effective health systems strengthening efforts. This is not to say that there are not longstanding efforts to improve and develop management skills among public health and healthcare professionals, but that management capacity building needs even more emphasis. Schools and programs of public health in the United States, the United Kingdom, and Europe have successful management programs and train numerous graduates in health management; however, we need to extend the reach of these programs and make training around management skills and tools more widely available in low-income settings and outside of formal degree programs. Doing so may foster the use of these skills and tools among healthcare staff and facilities in the structures and systems of countries without long-established schools of public health or business.7 Bradley and colleagues highlighted the potential value of academic programs specifically focused on health administration such as bachelors and masters programs in schools of public health with management concentrations or schools of business with healthcare concentrations.2 Collaborative programs or educational partnerships between such institutions and healthcare organizations are increasingly common in low-income settings and locations without easy access to similar training programs.8-11 Educational partnerships can be implemented fairly quickly and may be more cost-effective than establishing an academic program from scratch. Bradley et al suggest that Ministries of Health could play a role in funding access to such partnership programs. This may be financially feasible in some emerging nations; however, for many low-income nations this may be unrealistic. An alternative strategy may be to encourage and facilitate management capacity building through health systems strengthening project funding and donor agencies. Encouraging or even requiring management capacity building for funded health systems strengthening activities may be a good start. Management capacity building whether through new academic partnerships or revisions to current health training programs has the potential to change the effectiveness of global health systems strengthening. Evidence on Management in Health System Strengthening Like the field of health system strengthening, little evidence exists to inform management needs and best practices.12,13 At the macro level, better evidence can inform global health policies and donor funding that could support and justify more capacity building around management. At the micro level, better evidence can influence health systems strengthening activities and more effective management systems. A stronger 130
commitment to the monitoring and evaluation of health systems strengthening efforts, specifically those implementing quality improvement initiatives or management capacity building may contribute to filling this knowledge gap. While this may sound simple, measuring progress in health systems strengthening requires careful planning and sound metrics to assess changes in health systems function and performance. And although health systems strengthening has received considerable attention over the past decade, how to go about the process of monitoring and evaluating these activities is not always clear. Some assume that evaluating health system strengthening activities is too difficult given the nature of the work. Indeed, evaluation of these broad activities can be complex; however, our experiences with practitioners suggests that the amount of time, resources, and financial support necessary to conduct a rigorous evaluation of a health system strengthening activity is often underestimated and more limiting than study design issues. These issues aside, rigorous evaluation of health systems strengthening and the impact of management capacity building is crucial to building evidence for the field. As witnessed by the article by Bradley and colleagues, we appear to have arrived at a point in time where the value of management in global health efforts is getting some attention. How well we integrate management in health system strengthening activities will likely be determined by efforts toward management training and education and partnerships and the quality of the research that feeds back in to improve the system. Ethical issues Not applicable.
Competing interests
Authors declare that they have no competing interests.
Authors’ contributions
VAY conceptualized and drafted the manuscript. JB provided critical revisions to the manuscript. Both VAY and JB approved the final version.
References 1. Royston G. Meeting global health challenges through operational research and management science. Bull World Health Organ. 2011;89(9):683-688. doi:10.2471/blt.11.086066 2. Bradley EH, Taylor LA, Cuellar CJ. Management matters: a leverage point for health systems strengthening in global health. Int J Health Policy Manag. 2015;4(7):411-415. doi:10.15171/ ijhpm.2015.101 3. Kleinman CS. Leadership roles, competencies, and education: how prepared are our nurse managers? J Nurs Adm. 2003;33(9):451-455. doi:10.1097/00005110-200309000-00005 4. Baker S, Marshburn DM, Crickmore KD, Rose SB, Dutton K, Hudson PC. What do you do? Perceptions of nurse manager responsibilities. Nurs Manage. 2012;43(12):24-29. doi:10.1097/01.numa.0000422890.99334.21 5. Kerridge J. Why management skills are a priority for nurses. Nurs Times. 2013;109(9):16-17. 6. Novak S. Hands-On Medical Education in Rwanda. The New York Times. May 13, 2012. http://www.nytimes.com/2012/05/14/ world/africa/14iht-educlede14.html?pagewanted=all&_r=1. Accessed August 8, 2015.
International Journal of Health Policy and Management, 2016, 5(2), 129–131
Yeager and Bertrand 7.
Potter C, Brough R. Systemic capacity building: a hierarchy of needs. Health Policy Plan. 2004;19(5):336-345. doi:10.1093/ heapol/czh038 8. Institute of Medicine (IOM). The US Commitment to Global Health: Recommendations for the Public and Private Sectors. Washington (DC): National Academies Press (US); 2009. 9. Novak S. Hands-On Medical Education in Rwanda. The New York Times. Accessed May 13, 2012. http://www.nytimes. com/2012/05/14/world/africa/14iht-educlede14.html?_r=0. 10. Díaz-Monsalve, SJ. The impact of health-management training programs in Latin America on job performance. Cad Saude Publica. 2004;20(4):1110-1120. 11. Egger D, Travis P, Dovlo D, Hawken L. Strengthening
Management in Low-Income Countries. Making Health Systems Work: Working Paper Series Number 1. Geneva: World Health Organization; 2005. http://www.who.int/management/working_ paper_1_en_opt.pdf. Accessed October 23, 2015. 12. Adam T, Hsu J, de Savigny D, Lavis JN, Rottingen JA, Bennett S. Evaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions? Health Policy Plan. 2012;27(suppl 4):iv9-19. doi:10.1093/heapol/czs086 13. Hatt L, Johns B, Connor C, Meline M, Kukla M, Moat K. Impact Of Health Systems Strengthening on Health. Bethesda, MD: Health Finance & Governance Project. Abt Associates; 2015.
International Journal of Health Policy and Management, 2016, 5(2), 129–131
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